PRINTED ON PHYSICIAN’S LETTERHEAD

Letter Certifying Applicant’s Gender Change

I, ___________________________________________________________________________,
(Physician’s Full Name)

____________________________________, ____________________________________,
(Physician’s medical license/certificate number) (Issuing State/Country of license/certificate)

am the physician of _________________________________________________________,

(Name of Patient)
_________________________________________.
(Date of Birth of Patient)

with whom I have a doctor/patient relationship and whom I have treated, or

with whom I have a doctor/patient relationship and whose medical history I
have reviewed and evaluated.

_____________________________________________________________________________,
(Name of Patient)

has had appropriate clinical treatment for transition to ___________________.

(gender)

I declare under penalty of perjury under the laws of the United States that the
foregoing is true and correct.

_______________________________________
Signature of Physician
_______________________________________
Typed Name of Physician
_______________________________________
Physician’s Phone Number
____________________________________
____________________________________
Physician’s Address
____________________________________
Date

PRINTED ON PHYSICIAN’S LETTERHEAD